to screen or not to screen: update on screening mammography guidelines and dense breast legislation
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To Screen or Not To Screen:Update on Screening
Mammography Guidelines
Deanna J. Attai, MD FACSAssistant Clinical Professor of Surgery
David Geffen School of Medicine at UCLA
@DrAttai
No Disclosures
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Ideal Screening Test
•Find cancer before clinically evident• Improve survival due to early detection•Low false negative (sensitivity)•Low false positive (specificity)•Reasonable cost•Widely available
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“Early Detection Saves Lives”
•Mammograms may lead to improved survival from breast cancer by detecting some cancers at an earlier, more treatable stage
•Some breast cancers are so aggressive that early detection does not lead to improved survival
•Deadlier cancers not readily detected by screening (interval cancers)
Screening Mammography Limitations
•Sensitivity varies depending on:•Age, menopausal status•Use of HRT•Breast density•BMI•Other factors
Overdiagnosis / Overtreatment
• Increased DCIS (60K/year)•No significant change in mortality rate (40K/year)
•We are finding things that don’t need to be found
•However… once found – obligated to treat
Parameter USPSTF ACS ASBrS ACOG NCCN ACR
When to Start
50 45 45 40 40 40
Frequency Biennial Annual to age 54, then biennial. Should have opportunity for annual
Annual to age 54, then annual or biennial based on SDM
Annual Annual Annual
When to Stop
75 Biennial after age 75 if life expect >10 years
Biennial after age 75 if life expect >10 years
Ind. Ind. Life expect <5-7 years
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If you torture the data long enough it will
confess to anything
Darrell Huff 1954How to Lie With Statistics
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Evidence Based Guidelines
• Not all evidence is created equal• Guideline tries to answer the
question:“How certain can you be that the stated evidence is a true measure of the benefits and harms of treatment?”
http://guides.lib.uw.edu/hsl/ebptoolsAccessed 24 April 2016
Age 40’s
• BC uncommon, need to screen more women to prevent one death
• Higher cumulative rates of false-positive results, associated potential harms (biopsies, anxiety)
• Meta-analysis supports screening at age 40
• Early detection -> less aggressive treatment and a wide range of treatment options
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Biennial Screening
• Benefit of screening mammography maintained by biennial screening
• Biennial screening likely to reduce harms of screening by nearly half
• Benefit of annual screening outweigh risks as breast cancer mortality lower with annual screening
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When To Stop
• No women > 75 years included in randomized trials
• Benefits of screening occur several years after test, % of women who survive long enough to benefit decreases with age
• Older women at greater risk for dying of other conditions
• Most breast cancer detected in this age group is ER+
• Acknowledge limited data• High incidence of breast
cancer in elderly women• Clinicians should use
judgment when applying screening guidelines
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Insurance Coverage
• Affordable Care Act mandates insurance coverage for screening consistent with USPSTF guidelines
• Amendment requires use of 2002 guidelines for mammography
• Insurers required to cover [screening] mammography, with no cost-sharing, every 1-2 years for women starting at age 40
•Medicare fully pays for [screening] mammograms once every 12 months with no upper age limit
Pace et al., 2013; Factcheck.org, 2013
Breast Cancer Risk Factors
• Age, menarche / menopause / reproductive history• Family history, genetics• Chest wall irradiation• Breast density• BMI• Lifestyle: alcohol, saturated fat, activity / exercise• Unknown factors
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Courtesy Dr. Amy DegnimMayo Clinic Rochester
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Courtesy Dr. Amy DegnimMayo Clinic Rochester
Gail Model: cancer.gov/bcrisktool/
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Only considers 1° maternal relatives
International Breast Intervention Study (IBIS)Tyrer-Cuzick
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Courtesy Dr. Amy DegnimMayo Clinic Rochester
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Courtesy Dr. Amy DegnimMayo Clinic Rochester
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http://breasthealth.northshorelij.com/
George Edward Pelham Box 1919 –2013
Mathematician/Professor of Statistics University of Wisconsin
All models are wrong, but some are useful
Courtesy Dr. Kevin HughesMassachusetts General Hospital
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Courtesy Dr. Amy DegnimMayo Clinic Rochester
Hereditary Breast and Ovarian Cancer (HBOC)Red Flags
• Personal breast cancer ≤ age 50, ≤ age 60 if TNBC• 1° / 2° relative with breast cancer ≤ age 45• Any personal / family history ovarian cancer• Any family history male breast cancer• Ashkenazi Jewish with breast / ovarian / pancreatic cancer
at any age • Breast, ovarian, pancreatic in same person or on same side
of family
http://www.nccn.org/professionals/physician_gls/pdf/genetics_screening.pdf
Screening Mammography• Full field digital mammography• Same facility / compare
images
• 10-20% cancers not seen on mammogram
• 40-50% with dense breast
Breast Cancer ScreeningUltrasound
• Used to characterize mammographic abnormality
• May be helpful in women with dense breast tissue
• NOT FDA-approved for cancer screening; ABUS approved as adjunct to mammogram
Breast Cancer Screening – MRI
• High risk screening• Newly diagnosed, surgical
planning (controversial)
• Evaluates metabolic activity• IV contrast - gadolinium• Will not show calcifications,
non-invasive cancer • Up to 20% false positive
• FAST MRIKuhl et al J Clin Oncol 2014;32:2304-2310
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Breast Cancer DetectionOther Imaging Studies
• Tomosynthesis / 3D mammography• Contrast-enhanced mammography• PEM scanning – injection of FDG followed by breast imaging
– primarily for diagnosed breast cancer patients• BSGI – Tc-Sestamibi – diagnostic adjunct to mammography• Automated whole-breast ultrasound
• Thermography
BI-RADS Breast Imaging-Reporting and Data System
Assessment Categories:•Category 0 – Additional imaging needed•Category 1 – Normal•Category 2 – Benign findings•Category 3 – Probably benign (98%)•Category 4 – Suspicious (a, b, c)•Category 5 – Highly suspicious (>95%)•Category 6 – Known malignancy
BIRADS 3 Mammogram“Probably Benign”•MQSA – Mammography Quality Standards Act
• Mammography regulated by the FDA / lay letter mandated
•98% chance of being benign•Follow up appropriate•Q6 months x 2 years•Core biopsy may be an option
BI-RADS Breast Composition Categories
Level 1Fatty Breast
10%
Level 2Average Density
40%
Level 3Heterogeneous
40%
Level 4Extremely Dense
10%
Density grading is SUBJECTIVE
States with Dense Breast Notification Laws
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www.AreYouDense.org Accessed 04/24/2016
Breast Density• CA SB1538, Approved September 2012
Your mammogram shows that your breast tissue is dense. Dense breast tissue is common and not abnormal. However, dense breast tissue can make it harder to evaluate the results of your mammogram and may also be associated with an increased risk of cancer. The information about the results of your mammogram is given to you to raise your awareness and to inform your conversations with your doctor. Together, you can decide which screening options are right for you. A report of your results was sent to your physician.
• 23 State Laws evaluated• Readability of most at HS level or above• Poor understandability• Discontinuity with states’ average literacy
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Breast Density• 50% of patients are considered to have dense breast
tissue (80% < age 40)• Risk factor for breast cancer
• Heterogeneously dense RR 1.2 versus average density• Extremely dense RR 2.1 versus average density
• No increased breast cancer mortality based on density• Other breast cancer risk factors may be more important
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Factors Affecting Breast Density
•Age•Menstrual and reproductive history•Family history, genetics•BMI•Race•Unknown factors
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Courtesy Dr. Kevin HughesMassachusetts General Hospital
Density and BMI
BMI DensityBMI Density
Courtesy Dr. Kevin HughesMassachusetts General Hospital
Mammographic density can change
Menopause
Weight Gain
8 years
Courtesy Dr. Kevin HughesMassachusetts General Hospital
Gastric Bypass
Weight Loss
1 year
Mammographic density can change
Courtesy Dr. Kevin HughesMassachusetts General Hospital
Density RiskAsian High Low
Young High Low
Older, High BMI Low High
Counterintuitive
Harvey SABCS, 2015Breast Cancer Res. 2014 Oct 8;16(5):451
Courtesy Dr. Kevin HughesMassachusetts General Hospital
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Courtesy Dr. Alyssa ThrockmortonBaptist Medical Center
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Courtesy Dr. Alyssa ThrockmortonBaptist Medical Center
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Density is Only One Risk Factor
•Remember•Women with dense breasts may be at low risk
•Women with fatty replaced breasts may be a high risk
Courtesy Dr. Kevin HughesMassachusetts General Hospital
Dense Breast Management•Start with risk assessment (All Patients)
•Density not taken as stand-alone high risk marker•No survival benefit to additional imaging in average risk patient
•Not everyone needs supplemental imaging – HOWEVER - emotional, patient-driven factors
Ultrasound
Dense Breast Resources
• densebreast-info.org/• Breastdensity.info• breast.massrad.org/• drattai.com/areas-of-
focus/dense-breast-tissue
BreastScreeningDecisions.com
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BreastScreeningDecisions.com
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BreastScreeningDecisions.com
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Conclusions• Women and their breasts are
not one size fits all• Risk assessment essential
• Acknowledge uncertainties regarding risks and benefits of screening mammography
• Focus on shared decision making approach
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Society Guidelines• ACS
www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs
• ACOGhttp://www.acog.org/About-ACOG/News-Room/Statements/2016/ACOG-Statement-on-Breast-Cancer-Screening-Guidelines
• USPSTF (draft)www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementDraft/breast-cancer-screening1
• ASBrSwww.breastsurgeons.org/new_layout/about/statements/PDF_Statements/Screening_Mammography.pdf
“I have yet to see any problem, however complicated, which, when
you looked at it in the right way, could not be made still more
complicated.”Poul Anderson
Courtesy Dr. Kevin HughesMassachusetts General Hospital
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